Tag Archives: implicit bias

Throughout my long career as an ob-gyn, I’ve never been witness to a more intense national focus on the health care provided to American women than I have in this past year as president of ACOG. We’ve seen the deaths of pregnant women during and after childbirth take center stage as our understanding of the embarrassing U.S. maternal mortality rate grew. Countless labor and delivery unit closures at rural hospitals across the country have drawn attention to access to care, and many were shocked to learn that nearly half of U.S. counties lack a practicing ob-gyn. Legislative attacks on women’s health care have spread like wildfire, as both federal and state governments have attempted to restrict women’s ability to obtain health coverage and contraception, obstruct their access to abortion care, and institute punitive measures for pregnant women suffering from drug addiction. From the beginning, it was clear that the challenges facing our specialty—and to us, the physicians who care for women throughout their lifespan—are immense.

Before I officially took the reins in May 2017, we were already in the midst of the work, advocating against efforts in Congress to strip health care from millions of women through the repeal of the Affordable Care Act (ACA). Women stood to lose access to no-copay contraception, affordable maternity care, and essential preventive services. Women were at risk of returning to a time where they might have been denied coverage based on a prior C-section or had to pay more for insurance based on their gender, and Medicaid coverage for hundreds of thousands of low-income women would have been in jeopardy.

All of this played out in the news as ACOG fought fiercely alongside five other provider organizations in a coalition called the Group of 6. We batted down every iteration of legislation that would have been detrimental to the health of the women in this country. We lobbied, we rallied, we spoke to the media, and we galvanized ACOG members in support of this common cause. I am proud of what we accomplished, and I count the tremendous effort to defeat ACA repeal as one of the successes of my presidency. But, of course, there was much more work to be done.

In addition to my time at ACOG, a large focus in my career has been on perinatal health disparities and maternal mortality. More than 60 percent of maternal deaths are preventable, and more than 65 percent occur within the first week postpartum. One way ACOG is trying to address this is through the Preventing the Maternal Deaths Act. It would provide grant funding to states to establish or bolster maternal mortality reviews committees tasked with studying the causes of these deaths, and how they can be prevented. But these statistics also indicate that as providers, we need to change the paradigm when it comes to postpartum care.

As part of my presidential task force, “Redefining the Postpartum Visit,” we began with the premise that postpartum care is the gateway to lifelong health. It is not sufficient for women to have one visit six weeks after childbirth. It is critical for women to be seen within the first three weeks and then on an ongoing basis as needed—up to 12 weeks—to address several issues, including breastfeeding complications, postpartum depression, and chronic conditions such as diabetes and heart disease that often persist long after pregnancy. Women have multiple intersecting health needs, so we must facilitate care coordination between multiple providers to ensure women are able to seamlessly access the support and care they need. The task force just released a Committee Opinion this week and, in the coming months, a companion online toolkit for providers will be developed to assist in providing more holistic care. The latest article from ProPublica outlines how this reinvention of postpartum care will require “sweeping” changes in medical practice and throughout the maternal care system if we are to truly optimize the health of moms.

Another focus of my presidency has been on innovation in technology to improve women’s health, particularly telehealth and telemedicine. According to a Health Affairs study, nine percent of rural counties experienced the loss of all hospital obstetric services between 2004 and 2014. Through my “Telehealth Task Force,” we have been working to develop best practices in ob-gyn to improve access and address fragmentation in care. This has significant implications for the Levels of Maternal Care initiative, which focuses specifically on care access in rural settings. It relies on communication and care coordination between hospitals and birthing centers so that women can be transferred to and receive care from a facility that offers the level of care that best suits their needs. Telemedicine will be key in fostering that communication.

The task force remains committed to addressing issues regarding safety, payment, experimental e-obstetrics, virtual education, video conferencing, virtual monitoring, apps, and the crossover between inpatient and outpatient care. In the future, a telehealth Committee Opinion will be developed, and an ongoing work group will be established to continue this important effort. We are also combating the access issue from a legislative perspective through the Improving Access to Maternity Care Act. It has been passed in the House and currently resides in the Senate. Through this legislation, an official maternal health designation through the Health Resources and Services Administration will be created to better determine shortage areas. This in turn will allow more providers to serve in these areas through loan forgiveness programs and scholarships offered by the National Health Service Corps.

However, in our efforts to improve care on a systematic basis, we must not forget how critical it is to address implicit biases that permeate every aspect of care delivery and contribute to the racial health disparities that have led to our high maternal mortality rate. An often-repeated statistic, is that black women in the United States are three or four times more likely to die during childbirth than white women. It is shocking to most, but it shouldn’t be. Racial health disparities have a long history, and events as recent as what happened in Charlottesville last year remind us we still have a long way to go.

Even when black women have access to health care and advanced education, they are still at a disadvantage when it comes to receiving the quality of care on par with their white counterparts, and the constant stressors of racism and racial biases often put them at higher risk for chronic health conditions. Cardiovascular disease disproportionately affects black women, and stress has been linked as a possible contributor. I have been working with Dr. Lisa Hollier, ACOG’s incoming president, to partner on initiatives with the American Heart Association to address issues with women and cardiovascular disease, and I am confident that she will make marked improvements in this area.

It has been a whirlwind. I have traveled the country and the world in pursuit of advancing women’s health and ensuring that the clock is not turned back. I have worked alongside ACOG leadership and Fellows, including my esteemed colleagues, Drs. Hollier and Gellhaus, to improve maternal health for all women in the United States and serve as a model for women’s health care throughout the world. It has been a rewarding journey, and we have made incredible progress, but I am ready to pass the torch, and wish Dr. Hollier success as she carries it forward—there is much more work to be done, and I look forward to working with her this year as immediate past president.

Sixty-seven years ago, two tissue samples taken from a young, African-American woman diagnosed with cervical cancer led to the most important cell lines in medical research. Her name was, of course, Henrietta Lacks. Today, it would be difficult to find someone who isn’t familiar with her story. The “immortal” He-La cells have been used in more than 74,000 studies and have led to the discovery of the Polio and HPV vaccines, treatments for diseases, including diabetes and AIDS and other life-saving research around the world.

The contributions Lacks made to medical science have been heralded in the best-selling book, “The Immortal Life of Henrietta Lacks,” by the foundation created in her name, in countless news stories, in an HBO movie starring Oprah Winfrey and by the National Institutes of Health (NIH) through the establishment of a working group in her honor. In 2013, the NIH stated that Lacks and her family were the “greatest philanthropists of our time.” However, it wouldn’t be until 1987, 36 years after her cells were replicated and shared widely amongst the research community, that the NIH would institute a policy “encouraging” the inclusion of minorities in clinical studies. And it would be another six years before Congress would make it law through a section in the NIH Revitalization Act of 1993 entitled Women and Minorities as Subjects in Clinical Research. The reason for this move by the NIH is obvious. We cannot appropriately evaluate the effects of drugs in clinical trials without a racially diverse sample.

Therefore, it should be considered one of the greatest conundrums of our time that a black woman is responsible for thousands of breakthroughs in biomedical research and yet, in 2018, black women are three or four times more likely to die during childbirth than their white counterparts. When it was discovered that Lacks had cervical cancer, she had just given birth to her fifth child. At 31 years of age, Lacks suffered from a severe hemorrhage after childbirth and died eight months later after receiving routine cancer treatments and experiencing continued abdominal pain.

By today’s definition, Lacks would be counted among the women lost to maternal mortality. According to the Health Resources and Services Administration, the maternal mortality rate in the 1950s was 83.3 deaths per 100,000 live births. And while that number has decreased significantly since then, it is well-known that the United States is considered one of the most medically advanced developed countries— and yet, it has the highest maternal mortality rate amongst its peers, with even higher numbers for minority women.

I’ve done several media interviews on the topic of racial disparities in maternal mortality. Reporters always ask why these disparities exist, especially among well-educated, affluent black women where access to care is not an issue. In my interview with Essence magazine, I explain that there is a complex web of causes, but it often involves social determinants of health and structural barriers to health care. Whether an African-American woman is rich or poor, has a GED or a PhD, she is susceptible to morbidity and mortality and implicit biases of race and class. This not only impacts the quality of care she receives, but can also have negative physiological effects. The relationship between stress and how we respond to that stress physiologically has well-documented associations with prematurity and cardiovascular disease. The “microaggressions” that black women endure throughout their lives also make them predisposed to chronic conditions that can make a pregnancy high risk, such as hypertension and diabetes. It is a failure in our medical care as providers if we do not 1) recognize and accept this and 2) meet the necessary cultural and systemic challenges that impact health outcomes.

During my ACOG presidency, much of my focus has been on providing guidance on how to make these system level changes. In May, ACOG will release a revised “Optimizing Postpartum Care” Committee Opinion developed by my presidential task force, “Redefining the Postpartum Visit,” and the Committee on Obstetric Practice. It will stress the importance of the fourth trimester and propose a new paradigm for postpartum care. When women fail to receive postpartum care, it impedes management of chronic health conditions. Attendance rates are often lower among populations with limited resources, which contributes to health disparities.

As we celebrate Black History Month and the contributions of African-American mothers like Henrietta Lacks, we must honor her legacy by not accepting the deaths of black women from pregnancy and childbirth as a reality of race.